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THE IMPACT ANDSUSTAINABILITY OF MOBILETECHNOLOGY FOR HEALTHCARE DELIVERY IN MALAWI

KUNTIYA Kumbukani

Website: www.kkuntiya.tripod.comWordpress: www.kkuntiya.wordpress.com

Skype: kuntiya-k Email: [email protected]

November 2012

ICT Week 2012

How many senses do we have?

Acknowledgements:Mr. Kumwenda - supervisor

Dr. Maureen ChirwaMACRA

Organising committeeFamily

Contents1. Introduction2. Study Background3. Study sites4. Problem Statement & Study Aim

4.1 Study Objectives5. Methodology6. Study Limitations & Challenges7. Results8. Discussion9. Conclusion10. Recommendations11. References

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1. IntroductionReport of a study on the evaluation of mobile technology projects undertakenby UNICEF, Evangelical Association of Malawi (EAM), and FrontlineSMS MedicEvaluating effectiveness, impact andsustainability of mobile technology as atool for healthcare service delivery in

MalawiStaff shortages in our health facilities.

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2. Study BackgroundPopulation over 14 million

Health challenges like HIV/AIDS, maternalhealthLow numbers of health workersInadequate health facilities, long distancesCommunity Health Workers - Home BasedCare, CBOsSolution mobile technology projects by UNICEFs RapidSMS Mobile Technology project by EAM FrontlineSMS Medic at Namitete

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3.1 UNICEFs RapidSMS

3 pilot sites in Kasungu, Salima and Dedzafor nutrition surveillanceAddress issues Slow data transmission Incomplete and poor quality data sets High operational costs Low levels of stakeholder ownershipSolution: RapidSMS SMS + Internet

Rolled out in 2009

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3.1 UNICEFs RapidSMS

Objectives Identify possible improvements in data

transmission and quality by using mobiletechnology

Quantify the quality and transmissionimprovements

Customize RapidSMS for use with the existingINFSS system.

Adapt, if necessary, for national roll-out

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3.1 RapidSMS Project

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3.2 EAM Mobile Technology Project

Pilot - 2008, EAM in partnership withTearfund UK 2 sites at Malindi andNkope health centreVolunteers trained in HBC + ZainpayphonesPhones used for communication +business

Facility level 2 sites equipped withtelephone equipment

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3.2 EAM Mobile Technology Project

Aim - strengthening the referral systemObjectives: Improve the quality of care provided by the

HBC volunteers; Help the volunteers generate income from

the phones for their sustainability; Offer a technological solution that effectively

supports ICT related to health services

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3.2 EAM Mobile Technology Project

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3.3 FrontlineSMS: MedicRelies on free open source softwareplatform running FrontlineSMS coupledwith GSM technology (dongle)SMS communication between hospitalstaff and CHWs1 laptop computer acting ascommunication hub linked to 75 CHWsMajor site - Namitete (St. GabrielHospital)

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3.3 FrontlineSMS: MedicUsage: remote requests for medications

notification of patient deaths appointment reminders treatment adherence reminders patient or CHW queries requests for acute care replenishing CHWs SMS airtimeAimed at increasing efficiency of CHWs -maximizing productivity

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3.3 FrontLine SMS Project

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4. Problem Statement & Study Aim

Why the study? No collective and independent studies No literature that could be used to scale

up/replicate projects Implemented in isolation Most evaluations (if any) published externally

academic institutions Potential behind mobile technologyAim - determine impact of mobiletechnology usage for health care servicedelivery using the pilot projects

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4.1 Study ObjectivesInvestigate the effectiveness and impact of mobile technology projects for healthservice delivery;Analyse cost-benefits and sustainability of mobile technologies in health servicedelivery in Malawi; andInvestigate the process and strategiesused to implement mobile technologyprojects for health care in Malawi.

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4.1.1 Effectiveness and impactConsidering: Cuts in delivery costs and time S/LT Remote service delivery vs normal service

delivery Effect on the community health workers Effect on the livelihood of the HBC

volunteers, CHWs Comparison of technology and non

technology(control sites)

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4.1.2 Cost-benefit and sustainability

Benefits/costs that came aboutTechnology and activity appropriatenessPhase out preparedness mechanisms forsustainability

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4.1.3 Process and strategiesConsidered: Beneficiary targeting

Site identification Activity accessibility Project delivery - right form? Sufficiency of pre-project activities i.e. briefing,

mobilisation, training Project activity implementation Limitations and mitigation factors Recommendation for replication

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5. MethodologyType of Study EvaluationUsed both quantitative and qualitativeresearch methodsSampling - 1 site randomly picked perorganization

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5.1 Data CollectionKey Informant Interviews and FocusGroup DiscussionsExamined records and observations atfacility level by utilizing a checklistIn depth interviews

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6. Study Limitations and Challenges

Non availability of recorded dataNo external funding data collectionlonger than anticipatedEnvironment for data collection hospitals (disturbances)Time frame limited

No compromise on results

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7. Results52 participants F=25, M=27Age range 19 to 50 yearsEach of the participating project area hadon average 10 participantsAt non technology level - 26 participants

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7. Results

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7. 1.1 Results (Impact) - RapidSMS

Data transmission delays cut down fromover 2 months to immediately

Cut in transport costs - data forms nolonger taken to Lilongwe physicallyResponses immediate feedback dataquality improvedData entry & analysis costs reduced toalmost zero automatically by system

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7. 1.2 Results (Impact) - EAMTravel costs and delays reduced by both communityhealth workers and hospital staff K200 K20Used to spend almost whole day away to the hospitalbut now seconds on the phoneMedical assistant managed to cut down by 100% onall in hospital travel requirementsEmpowerment of HBC members through effectivepatient registration and referralCuts in travel times by over 50% by Medical Assistantand HBC supervisor - conduct supervision/conductoutreach clinics

CBOs were able to use part of the proceeds to buybasic items and medicine for the home based carepatients

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7.1.2 Results (Impact) -EAM

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-

5,000.00

10,000.00

15,000.00

20,000.00

25,000.00

30,000.00

35,000.00

Total Health 975.00 740.00 517.50 280.00 500.00 500.00 630.00 600.00 400.00

Total Business 3,057.50 21,712.50 28,617.70 31,475.00 27,635.00 15,712.50 27,535.00 10,732.50 10,090.00

April May June July Aug Sept Oct Nov Dec

7. 1.2 Results (Impact) -EAM

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CBO NameRegistered

PatientsReferredPatients %

Mkadabwi 78 16 21%

Chikomwe 71 48 68%

Nkuli 70 4 6%

Mwalembe 60 9 15%

Mwanyama 42 1 2%

Lusalumwe 172 4 2%

Chiwalo 124 70 56%

Illiyoni 78 20 26%

Total 695 172 25%

7. 1.3 Results (Impact) - Namitete

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Message Content

Number of

Messages

Percent

of TotalPatient Reporting or Referrals 410 30.83%Request for SMS Credits 219 16.47%Reporting Symptoms 199 14.96%Other 173 13.01%Request for Help 107 8.05%Patient Death Notification 75 5.64%Meetings 60 4.51%Requesting Supplies 59 4.44%Phone Problems 28 2.11%Total 1330

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7.1.3. Results (Impact) - Namitete

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Department Pre-pilot Post-pilot % Increase

TB 100patientsenrolled

200patientsenrolled

100%

ART 25reports/month

67reports/month

168%

7.2.1 Results Cost-Benefit &Sustainability RapidSMS

Considerable costs server, mobile phones,internet presence, toll free number

Reduced delays in data transmissionImproved data quality - national level @2.7% (n=517)Pre-project phase needed data entry &analysis, re-entering of data - automationPrivacy and immediate attentionControl over drop outs & was easy tofollow up

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7.2.2 Results Cost-Benefit &Sustainability - EAM

Costs: payphones, PABX installation atMalindi, HBC trainingEnhancing capacity building & infrastructureIncrease in patient registration, referral &follow upIncreased CBO income baseEasy communication & networking

No privacy - stationed at public placesPhones deployed along with ULCHs

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7.2.3 Results Cost-Benefit &Sustainability - Namitete

Costs: Laptop + GSM, mobile phonesConstant breakdown of phones and solar chargersReduced costs of data transmission to the hospital -5Kms/bicycleTimely response to CHWs requests for support orambulance servicesPatients felt very closer to hospital careProvision of airtime by hospitalProvision of phones contributed towards easycommunication & networkingRecharge of phones a burden to CHWsPrivacy and immediate attentionEasy technology for both (automated system)Single laptop a hassle move round delivering messages

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7.3.1 Results Process & Strategies

All projects had a shortfall in terms of theway they were designedLikely contribution to the shortfalls thatsome of them encountered.

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Criteria Project

RapidSMS EAM FrontlineSMSTargeting Under 5 visiting Growth

Monitoring Centres (HSAs)Community based structures CBOsand volunteers

Community based structures CHWs

Siteidentification

UNICEF implementation districts purposely selected withvarious reporting trends

Existing partnership through EAMand CHAM facilities

Existing collaboration betweenfunders and project site

Accessibility ofservices

Under five children andguardians/parents

Both home based care patients andgeneral community

Home based care patients

Delivery inright format

Yes Yes, privacy of patients compromisedfor some patients

Yes, privacy of patients promoted

Pre projectactivities Training provided to users,briefing to stakeholders Training provided to users, briefing tostakeholders, minimal on joint project

designTraining provided to users, briefingto stakeholders, and ongoingproject activities

Activityimplementation

Joint implementation byUniversity of Columbia, UNICEFand Bunda College

Joint between beneficiary andimplementers EAM providedfunding including operational costs

Joint implementation and is stillgoing on

Limitations& Mitigation

High cost of SMSing, High costof equipment (computer andinternet connection), availabilityof phones amongst HSAs

Availability of electricity for theserver

High cost of equipmentCBOs stopping activities at end of pilot phaseHigh staff retentionCompletion from other sources of communication (not sorted out aspilot phase closed)

Use of recycled phones, Use of solar chargers high cost for recharging, transport problems for CHWs to conduct home visitsNetwork problems phones

Provision of toll free number Computers and internetprocured by UNICEF

Nothing p ro je ct ph as ed o ut N ew p ho ne s a cq ui re dNetwork upgraded

Recommendations forreplication

Recommended but cost of internet might not be sustainableto most sites, computer softwareneeds some customization

Expensive to procure projectmaterials (pay phones)

Highly recommended, cheap toimplement

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8. DiscussionEffectiveness and impact of projects

time savings cost savings

Additional or available resourcesReinforces international campaigns and other studiesand compares wellRapidSMS - great potential for achieving greatereffectiveness

reduced delays in data transmission improved data quality reduced manpower requirement reduced participant dropout rates improved reporting rates

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8. DiscussionMore services deployed palliative careat NamiteteSeeing more patientsAdditional costs to beneficiaries phonerechargingSustainability and ownership problems externally funded, academic institutionsCapital outlay EAM vs UNICEF andFrontLine SMS

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9. ConclusionFirst of its kindAll have contributed towards impactBoth patients and care givers appreciated introduction improvements in care, qlty + qtyReduction in stigma privacyAdvanced care acquired easily call ambulanceDrop outs low and easily traced (TB + ART)Report generation easy RapidSMS + FrontLineSMSNo collaboration amongst stakeholdersNo standards set out by government/regulator i.e pilots,pilots for how long? Beneficiary protection

Solution in itself and not part of the solution wrongSustaining the momentum - challenge

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10. 2 Recommendations - GovtMoH take a leading role to facilitate

stocktaking and awarenessEstablish minimum standardsPromote adoption and usage of mobiletechnology for social services - MACRAReduction of ICT costs - removal of tax onICT equipmentSupporting academic/research institutions -contributing towards attainment of MDGs(mine was turned down by )

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10. 3 Recommendations Implementers/Funders

Formal forum should be established -share any updates and collaborate effortsEngage MNOs innovations, negotiate forany discounts i.e. social responsibilityinitiatives (CallDoc)Social marketing telecentresExit strategies - safeguard sustainability;Case study of all the projects - learningand documentation purposes

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10. 4 Recommendations Community Members

IGAs - compliment towards cost of running projects i.e. buying airtime, re-

charging phone batteriesMore male involvement

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11. ReferencesTearfund UK, Communication Technology Project Malawi Feasibility Study, December 2006Broadhead R.L. and MuulaA.S. Creating a medical school for Malawi: problems and achievements,Biomedical Journal 2002Nadim Mahmud, JoceRodriguez, Josh Nesbit, Mobiles in Malawi: A text-based intervention to bridge thepatient-physician gap in the rural developing world, Global Pulse, Vol. 6, 2010Karlstad University, Proceedings of 1 st International Conference on M4D, December 2008Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology forHealthcare in the De veloping World. Washington, D.C. and Berkshire, UK: UN Foundation-VodafoneFoundation Partnership, 2009Mobile Health, http://www.wikipedia.org/wiki/mhealth , Accessed 4 July 2010, 11.00amSheila Kinkade, and Katrina Verclas, Wireless Technology for Social Change: Trends in Mobile Use byNGOs, United Nations Foundation - Vodafone Foundation Partnership, 2008Smith MK and Henderson-Andrade N. Facing the health worker crisis in developing countries: a call forglobal solidarity, WHO, 2006Laura Naismith, Peter Lonsdale, Literature Review in mobile technologies and learning, Report 11,NestaFuturelab SeriesNigel Scot, Simon Batchelor, Jonathan Ridley, Britt Jorgensen, The Impact of mobile phones in Africa,Commission for Africa, 2004Chetan Sharma, Mobile services evolution 2008 2018, United Nations Foundation

Julie Solo, Expanding Contraceptive Choice to the Underserved Through Delivery of Mobile OutreachServices a handbook for program planners, USAID, 2009

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10. Referenceshttp://www.cell-life.org/content/blogcategory/13/135/ Visited July 12, 2010, 11:40amhttp://www.simpill.com/ Visited July 12, 2010, 11:30amhttp://www.voxiva.net/rwanda.asp Visited July 12, 2010, 12:00pmRapidSMS: A Reviewhttp://www.mobileactive.com Last accessed July 28, 2010, 10:00am

Journal of Information Technology Impact, Vol. 3, No. 2, pp. 69-76, 2003 Information and CommunicationTechnology in Nigeria, The Helath Sector Experience ObafemiAwolwo University, NigeriaMechael, Patricia N., Exploring Health-Related Uses of Mobile Phones: An Egyptian Case Study, 2006Rafael Anta, ShireenEl-Wahab, and Antonino Giuffrida, Mobile Health: The potential of mobile telephonyto bring health care to the majority, Inter-American Development Bank, Innovation Note, February2009Globalization and Health 2006, 2:9. Can the ubiquitous power of mobile phones be used to im provehealth outcomes in developing countries? http://www.globalizationandhealth.com/content/2/1/9 Lastaccessed 12 January 2010, 12.00pmMedical Journal of Australia, Vol 183, No. 7, 2005. Use of SMS text messaging to improve outpatientattendanceSundararamanT. Community health-workers: scaling up programmes, Lancet 2007, 369Ministry of Health and Population, Malawi (2004), Treatment of AIDS, the two year plan to scale upantiretroviral therapy in MalawiUNAIDS (2006), 'UNAIDS 2006 Report on the global AIDS epidemic' , Annex 2: HIV/AIDS estimates anddata, 2005

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Mobile Technology thesixth sense:

Challenge? How do weintegrate mobile technologyTowards Improving Lives of

Malawian People?

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